Running Head: MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
MINDFULNESS AND RUMINATION: MEDIATORS OF CHANGE IN DEPRESSIVE
SYMPTOMS? A PRELIMINARY INVESTIGATION OF A UNIVERSAL MINDFULNESS
INTERVENTION FOR ADOLESCENTS
Trainee Name
Nicola Motton, College of Life and Environmental Science,
University of Exeter
Supervisor
Willem Kuyken, College of Life and Environmental Science,
University of Exeter
Nominated journal
Behaviour Research and Therapy
Word count
7,075 (13,313 with appendices)
This work is submitted in partial fulfilment of a doctoral degree in clinical psychology.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
2
Table of Contents
Abstract ………………………………………………………………………………….
3
Introduction ……………………………………………………………………………….
4
Method ………………………………………………………………………………….
10
Statistical Analyses ……………………………………………………………………….
15
Results ………………………………………………………………………….…………
17
Discussion ……………………………………………………………………...…………
24
References …………………………………………………………………….......………
32
Appendix A: Expanded Results ………………………………………………..…………
41
Appendix B: Journal’s Author Guidelines …………………………………….………….
43
Appendix C: Ethical Approval letter …………………………………………..…………. 61
Appendix D: Questionnaires …………………………………………………...…………
62
Appendix E: Consent Forms and Debriefing Statement ………………………………….
65
Dissemination Statement …………………………………………………………………. 68
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
3
Abstract
Mindfulness-based interventions reduce depressive symptoms and rumination, and enhance
mindfulness in adults; this non-randomised controlled feasibility study aimed to determine
whether these conclusions apply to young people, and whether mindfulness and rumination
mediate the effect on depressive symptoms. Participants aged 12-16 received a nine-week
universal mindfulness intervention in schools delivered by trained teachers (intervention group,
N = 256) or their regular school curriculum (control group, N = 266). Intervention schools were
matched to control schools on key variables (publicly-funded versus private, mainstream versus
special needs). Young people who received the intervention reported fewer depressive symptoms
post-intervention relative to controls, which was maintained at three-month follow-up.
Mindfulness and rumination were unchanged immediately after the intervention, however by
follow-up, intervention participants were significantly more mindful and less likely to ruminate
than controls. The extent to which young people practiced mindfulness was negatively correlated
with depressive symptoms at post-intervention and follow-up, positively correlated with
mindfulness at post-intervention and follow-up, and positively correlated with rumination at
follow-up. This universal mindfulness intervention shows promise for reducing depressive
symptoms, reducing rumination and increasing mindfulness in young people, however further
research is warranted, particularly regarding the mechanisms of change.
Keywords: Depressive symptoms, mindfulness, rumination, adolescence, prevention.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
4
Mindfulness and rumination: Mediators of change in depressive symptoms? A preliminary
investigation of a universal mindfulness intervention for adolescents
The World Health Organisation (WHO) has ranked unipolar major depression as one of
the most burdensome diseases in terms of both the number of years lost to disease-related
disability, and premature mortality (Murray & Lopez, 1996). It is expected to become the most
burdensome disease in developed countries by 2030 (Mathers & Loncar, 2006). Depression can
be not only disabling (Judd et al., 2000a), but also often runs a chronic course (Judd, 1997; Judd,
2000b); around 75% of individuals will relapse within five years of their first episode (Kennard,
Emslie, Mayes, & Hughes, 2006). Importantly, early age of onset is associated with more
chronic and recurrent depression in adulthood (Coryell et al., 2009), greater intention to act on
suicidal ideation when depressed (Thompson, 2008) as well as a higher likelihood of attempted
suicide in later life (Williams et al., 2012; Zisook et al., 2007). Research on the course of major
depression has suggested it is preferable to consider depressive symptoms on a continuum with
depression (Lewinsohn, Solomon, Seeley, & Zeiss, 2000), as depressive symptoms are both
predictive of later depression (Pine, Cohen, Cohen, & Brook, 1999; Shankman et al., 2009) and
associated with distress and functional impairment in their own right (Aalto-Setälä, Marttunen,
Tuulio-Henriksson, Poikolainen, & Lönnqvist, 2002). In fact, the extent of depressive symptoms
is associated in a linear fashion with psychosocial impairment and the probability of developing
depression, leading some researchers to conclude that low-grade depressive symptoms should be
as much a target for intervention as depressive symptoms that are deemed to fall above the
threshold for depression (Lewinsohn et al., 2000). Longitudinal studies find depressive
symptoms peak markedly in mid-adolescence (Ge, Lorenz, Conger, & Elder, 1994; Saluja et al.,
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
5
2004). It is imperative therefore, that interventions are developed to reduce depressive symptoms
in this age group, in order to improve adolescent wellbeing and functioning, and prevent adverse
outcomes later in life.
Interest in preventative interventions for depression has grown in the last few years, with
promising findings to date (Cuijpers, van Straten, Smit, Mihalopoulos, & Beekman, 2008),
however a recent large scale RCT (N = 5030) of classroom-based Cognitive Behavioural
Therapy (CBT) found no reduction in depressive symptoms in at-risk adolescents compared to
an attention control group or usual school provision (Stallard et al., 2012). This finding calls for
alternative means of prevention to be considered.
Any successful preventative intervention must target factors known to predict and
maintain depressive symptoms. Rumination, defined as “behaviours and thoughts that focus
one’s attention on one’s depressive symptoms and on the implications of these symptoms”
(Nolen-Hoeksema, 1991, p. 569), has been strongly implicated in the onset and maintenance of
depression; rumination has been found in prospective studies to predict higher levels of
depressive symptoms following a stressful event, even after accounting for baseline levels of
depressive symptoms (Nolen-Hoeksema & Morrow, 1991), contribute to the maintenance and
exacerbation of depressive symptoms in adolescents (Burwell & Shirk, 2007), and predict the
onset of new depressive episodes in adolescents (Broderick & Korteland, 2004), as well as adults
(Nolen-Hoeksema, 2000). Given the substantial body of research that strongly implicates
rumination in the development and maintenance of depressive symptoms and depression,
preventative interventions should aim to reduce rumination. If an intervention were to reduce
adolescents’ tendency to ruminate, it could be expected to reduce depressive symptoms and the
likelihood of later depression.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
6
Mindfulness may be one such method of overcoming rumination, as a means to reducing
depressive symptoms. Mindfulness has been described as “the awareness that emerges through
paying attention on purpose, in the present moment, and non-judgementally to the unfolding of
experience moment by moment” (Kabat-Zinn, 2003, p. 145). The two most established
mindfulness programmes are the eight-week Mindfulness-Based Cognitive Therapy programme
(MBCT; Segal, Williams, & Teasdale, 2013) designed to prevent depressive relapse for
individuals who have experienced three or more episodes of depression, and the eight-week
Mindfulness-Based Stress Reduction course (MBSR; Kabat-Zinn, 1990), designed to aid the
management of stress, pain and physical ill health in the general population. Both interventions
reduce depressive symptoms in adults; MBCT is effective in preventing the recurrence of
depressive episodes in adults with chronic depression (Kuyken et al., 2008; Teasdale et al.,
2000), indeed, the evidence is sufficiently robust for NICE (2009) to recommend MBCT as an
intervention for preventing relapse in adults who experience recurrent depression. In addition to
the research on MBCT, studies of MBSR suggest it can reduce depressive symptoms in nonclinical samples of adults (Deyo, Wilson, Ong, & Koopman, 2009; Labelle, Campbell, &
Carlson, 2010).
Thus research with adults supports the premise that mindfulness interventions can be
used to reduce depressive symptoms in clinical and non-clinical adult samples. Considerably less
research has been conducted examining the application of mindfulness interventions for young
people, however initial research suggests that, at least in the form of MBSR, mindfulness does
indeed reduce depressive symptoms in adolescents presenting with mental health problems
(Biegel, Brown, Shapiro, & Schubert, 2009). The literature on the application of mindfulness
interventions for children and adolescents is growing, however no studies to date have examined
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
7
the mechanisms of change for mindfulness interventions in this population (Harnett & Dawe,
2012).
Understanding the mechanisms through which mindfulness interventions produce change
in depressive symptoms is essential, as for interventions to be maximally effective, the aspects of
the intervention that bring about change must be well understood in order that they may be
enhanced (Kazdin, 2007). The current study examines the hypothesis that a mindfulness
intervention for young people may reduce depressive symptoms as a result of reducing
rumination. In this context, reduction in depressive symptoms is the outcome, and reducing
rumination as a result of learning mindfulness, the hypothesised mechanism through which
mindfulness interventions may exert their effect. The concept of mechanisms of change is
closely related to the concept of mediation; a mediator is a variable that accounts statistically for
the effect of an intervention on a given outcome. In order for mediation to be established, there
must be significant relationships between the intervention and the outcome (depressive
symptoms), the intervention and the process variables through which the intervention is expected
to exert its effect (mindfulness and rumination), and the process variables and the respective
outcome (depressive symptoms). Furthermore, the process variables must account uniquely for
some of the variance of the intervention on depressive symptoms, after the effect of the
intervention itself has been accounted for. A temporal sequence of events is a pre-requisite to
establish mediation, as mediation presumes causal links between process and outcome. That is
the intervention effects change in process variables (reduced rumination and increased
mindfulness), leading to a change in outcome (reduced depressive symptoms). Therefore in order
to establish mediation, change in process variables must occur prior to change in outcome,
otherwise it cannot be concluded that the outcome changed as a result of change in process
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
8
variables. Research on preventative interventions must measure both outcome and process
variables, in order to establish how interventions work, so that effectiveness can be maximised.
Initial evidence with adults supports the notion that mindfulness interventions reduce
depressive symptoms by reducing rumination (e.g. Labelle et al., 2010). Certainly for MBCT it
has been theorised that mindfulness prevents depressive relapse by allowing individuals to
become more aware of depressive thoughts and feelings, and to observe them from a neutral
stance, without engaging in the ruminative processes that perpetuate low mood and lead to
depression (Teasdale et al., 2000). Indeed, research supports this theoretical supposition; the
effect of MBCT on depressive symptoms is mediated through enhancing mindfulness (Kuyken et
al., 2010). Research on MBSR concurs with this finding, MBSR has been found not just to
reduce depressive symptoms in adults, but to reduce rumination and enhance mindfulness with
adults who are predominantly not depressed (Deyo et al., 2009). Furthermore, reductions in
rumination have been found to mediate the effect of MBSR on depressive symptoms in adults
(Labelle et al., 2010).
Research to date suggests mindfulness interventions may be effective at reducing
depressive symptoms in adults (Deyo et al., 2009; Kuyken et al., 2008; Teasdale et al., 2000),
and potentially with adolescents with mental health problems (Biegel et al., 2009). Some
evidence suggests this may occur as a result of reducing rumination and enhancing mindfulness
(Deyo et al., 2009; Kuyken et al., 2010; Labelle et al., 2010). However it is yet to be determined
whether the reduction in depressive symptoms following mindfulness interventions can be
replicated in other populations of adolescents (such as non-clinical populations) and whether the
mechanisms of change hypothesised here are valid for adolescents, that is, whether depressive
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
9
symptoms are in fact reduced as a result of improved ability to react to mental events in a more
adaptive manner: mindfully rather than ruminatively.
This non-randomised controlled feasibility study (Craig et al., 2008) investigates these
questions by examining the effect of a universal school-based mindfulness intervention
specifically designed for adolescents on depressive symptoms, mindfulness, and rumination.
Universal programmes target the general population irrespective of their level of symptoms or
risk of developing a disorder, whereas selective interventions target high risk individuals who are
asymptomatic, and indicated interventions target individuals with subthreshold symptoms
(Cuijpers et al., 2008). Universal interventions can be advantageous to selective or indicated
programmes as they are low cost and non-stigmatising (Stallard et al., 2012), and delivering
these within a school setting is a pragmatic and powerful means of affecting the wellbeing of
young people (Weare & Nind, 2011). The Mindfulness in Schools Programme (MiSP) is a
universal mindfulness intervention, which aims to enhance the wellbeing and mental health of
young people. This nine-week complex intervention (Craig et al., 2008) was designed
specifically for adolescents, and delivered during regular school lessons by trained secondary
school teachers. Given the sharp rise in depressive symptoms in mid-adolescence (Ge et al.,
1994; Saluja et al., 2004), the effects of the intervention are examined on a group of adolescents
in the 12-16 year age range.
This study asks three questions: Does participation in this universal school-based
mindfulness programme reduce depressive symptoms in young people, relative to young people
in matched control groups who receive usual school provision? Do young people who take part
in the programme learn to respond more adaptively, that is does their tendency to respond in a
mindful way increase, and their tendency to respond in a ruminative way decrease, compared to
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
10
their usual school provision counterparts? And for young people who participate in the
programme: Are changes in depressive symptoms mediated by improvements in their ability to
be mindful, and reductions in their tendency to ruminate?
Correspondingly there are three hypotheses for these questions. Firstly, it is predicted that
participation in the mindfulness programme will reduce young people’s depressive symptoms
relative to controls, and that this difference will be apparent following the intervention and at
three-month follow-up, during the stressful summer exam period. Secondly, it is predicted that
participation in the mindfulness programme will increase young people’s tendency to be mindful
and reduce their tendency to ruminate relative to controls, and that this difference will be
apparent following the intervention and at three-month follow-up. Thirdly, it is predicted that for
young people who participate in the mindfulness programme, reductions in depressive symptoms
will be mediated by increases in their tendency to be mindful and reductions in their tendency to
ruminate. Finally, an exploratory approach is adopted to understand the relationships between the
amounts of mindfulness practice young people engaged in and changes in outcome (depressive
symptoms) and process variables (mindfulness and rumination).
Method
Design and Procedure
This study was embedded in a larger trial that examined the feasibility and efficacy of the
MiS (Mindfulness in Schools) programme on a range of mental health and wellbeing outcomes.
Readers interested in knowing more about the wider project are referred to the manuscript for
further information (Kuyken et al., 2013). The current study employed a non-randomised
controlled parallel group (mindfulness intervention versus matched control group) design.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
11
Outcome (presence and frequency of depressive symptoms) and process measures (mindfulness
and rumination) were measured pre- and post- intervention, and at follow-up (three months after
baseline).
The MiS programme consisted of nine weekly hour-long sessions delivered during
regular school lessons, usually in place of religious studies or personal, social, health and
economic (PSHE) education lessons. The programme was delivered by schoolteachers; the
programme developers themselves, and teachers who had been trained and deemed competent by
them. Participants in control schools received their regular school curriculum, including elements
that related to social or emotional wellbeing.
Schools that had teachers who were trained and deemed competent at delivering the
programme were selected for the intervention arm. Control schools were selected due to having
teachers who were interested, but not trained in the programme, to control for the effect of
teacher interest. Intervention and control schools were matched on several key variables: feepaying or public-funded status, school year group, and the school’s academic record (based on
published Office for Standards in Education (OFSTED) findings). Head Teachers were
approached and offered the opportunity for their school to be included in the study. Parents
received a letter from the Head Teacher informing them their child was taking part in a research
study and allowing them to retract their child from the study. Participants who chose not to take
part were provided with alternative activities in place of the mindfulness intervention, and did
not complete the measures. The study received ethical approval from the University of Exeter
Psychology Department Ethics Committee (Ref. 2011/527, December 2011; Appendix C).
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
12
The MiS Programme
The MiS programme material is drawn from both mindfulness-based stress reduction
(Kabat-Zinn, 1990) and mindfulness-based cognitive therapy (Segal et al., 2013), and has been
developed over the last 4 years, in response to feedback from the 200 teachers who have received
training in the programme and the 2,000 young people who have taken part. The programme
aims to teach young people about the benefits of mindfulness and to increase their capacity for
being mindful through regular in-session and out of session practice. The 9-week programme
employs a number of elements considered important to the effectiveness of school-based
wellbeing programmes (Durlak & DuPre, 2008; Weare & Nind, 2011), such as shorter practices,
age-appropriate teaching material, an explicit and experimental teaching style, and strong fidelity
to the programme manual. Young people were provided with a programme handbook and access
to guided mindfulness practices with CD or MP3 audio files.
Participants
The intervention was universal, thus all consenting participants took part in the study; no
participants were excluded on any grounds.
Measures
Data collection occurred at three time points; pre-intervention data were collected at the
start of the second school term (January 2012), post-intervention at the end of the second school
term (March 2012) and follow-up data in the final term (May 2012). Follow-up occurred during
end of year exams, thus providing a test of the intervention’s effects during a period of academic
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
13
pressure. Data were collected via online or paper based questionnaires, whichever was most
convenient for the teachers at their school.
Outcome measure: Depressive symptoms
The presence and severity of depressive symptoms were measured using the 8-item
version of the Centre for Epidemiological Studies Depression Scale (8-item CES-D; Steffick,
2000). The 8-item version is a shortened version of the original twenty-item scale (Radloff,
1977), which is a widely used measure of the frequency and severity of depressive symptoms in
the general population that has good psychometric properties (Fendrich, Weissman, & Warner,
1990; Radloff, 1991). The 8-item scale requires respondents to rate how much of the time over
the past week they felt or behaved in certain ways on a 4-point Likert scale from “none or almost
none of the time” to “all or almost all of the time”. A sample item is “ How much of the time
during the past week have you felt depressed?” Total score is achieved by summing all items
(range 8-32). Though not as widely used, the shortened version has demonstrated acceptable
internal consistency (α = .81 male sample, α = .85 female sample), and validity, indicated by
Confirmatory Factor Analysis, which despite a significant χ² value, found a score of over .90 for
the Tucker Lewis Index and Comparative Fit Index, and a Root Mean Square Error smaller than
.80, indicative of good validity (Bracke, Levecque, & Van de Velde, 2008). The measure was
deemed appropriate for the age group, having been recently used in a large-scale European study
of over 43,000 young people aged 15 and above (Bracke et al., 2008), and piloted with a group
of young people whose feedback supported the acceptability of the measure.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
14
Process measures
Mindfulness
Propensity for mindfulness was measured using the Cognitive and Affective
Mindfulness Scale-Revised (CAMS-R; Feldman, Hayes, Kumar, Greeson, & Laurencceau,
2007). This 12 item abbreviated version of the original 18-item scale (Kumar, 2005) pertains to
four facets of mindfulness: attention, present-focus, awareness, and acceptance. Items are rated
on a 4-point Likert scale from “rarely or not at all” to “almost always”. A sample item is “I am
able to accept the thoughts and feelings I have”. The scale has demonstrated acceptable internal
consistency in two samples (sample 1 α = .74; Sample 2 α = .77), and convergent and
discriminant validity with measures of related constructs (Feldman et al., 2007). The measure
was used in a recent study of young people aged 11-17 (Hennelly, 2011), and feedback from
piloting with young people supported its acceptability with this age group.
Rumination
For a brief measure of rumination, the rumination subscale of the Cognitive Emotion
Regulation Questionnaire (CERQ; Garnefski & Kraaij, 2007) was used. The full 36 item
questionnaire measures a total of nine different cognitive coping strategies, has been validated
for use with individuals aged 12 and above, has good convergent and discriminant validity
(poorer emotion regulation scores correlate positively with depression and anxiety) and good
reliability (α ranged from .75 to .87; Garnefiski & Kraaij, 2007). The four items of the
rumination subscale were rated on a 5-point Likert scale from “never or almost never” to
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
15
“always or almost always”. A sample item is “I dwell upon the feelings the situation has evoked
in me”.
Practice
The extent to which intervention participants had practiced using mindfulness was
assessed at three-month follow-up with the question: “During the .b course you were taught a
range of mindfulness practices. Since the end of the course how often have you used these
practices?”. Frequency of practice was rated using a 6-point scale (never to almost every day).
Statistical Analyses
Descriptive statistics are reported for baseline data in the control and intervention arms to
enable comparison. Baseline data were examined using independent t-tests and Chi-square to
determine any pre-existing imbalances in demographic, outcome or process variables, to indicate
which variables to use as covariates in later analyses.
In relation to the first research question; whether participation in the mindfulness
programme reduced depressive symptoms relative to controls at post-intervention and at threemonth follow-up, between-groups analyses in the form of an ANCOVA was run, with depressive
symptoms at post-intervention and three-month follow-up as the dependent variables, and
condition (intervention or control) as the independent variable. Given that participants in this
study were not randomised to condition, gender, age, ethnicity and baseline level of depressive
symptoms were used as covariates, to ensure that observed differences could be attributed to the
intervention rather than to any baseline imbalances in demographic variables or pre-existing
individual differences in symptomology.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
16
In relation to the second research question; whether adolescents who took part in the
programme learnt to respond more adaptively, that is did their tendency to respond in a mindful
way increase, and their tendency to respond in a ruminative way decrease, compared to their
usual school provision counterparts, a further ANCOVA was run, to provide a between-groups
measure of mindfulness and rumination in the intervention group compared to controls at postintervention and at follow-up. Mindfulness and rumination at post-intervention and three-month
follow-up were the dependent variables, and condition (intervention or control) the independent
variable. In order to account for lack of randomisation to condition, gender, age, ethnicity and
baseline mindfulness and rumination were used as covariates. This allowed the observed effects
to be attributed to the intervention and not imbalances in gender ratio between conditions, or preexisting differences in mindfulness or rumination.
In relation to the final research question, that is whether change in depressive symptoms
was mediated by improvements in young people’s ability to be mindful and reductions in their
tendency to ruminate, within-groups meditational analyses would be conducted using Baron and
Kenny’s (1986) approach. Firstly, in order to establish whether the mindfulness intervention is
related to depressive symptoms, a simple regression would be conducted with depressive
symptoms at follow-up as the dependent variable, and mindfulness intervention as the predictor.
Assuming the mindfulness intervention does predict depressive symptoms at follow-up, step two
would entail determining whether the mindfulness intervention predicts change in mindfulness
and rumination post-intervention. A simple regression using change scores (from baseline to
post-intervention) for mindfulness and rumination as dependent variables, and mindfulness
intervention as the predictor would be conducted. If step one and two were completed
successfully, this would demonstrate that the intervention correlates with both outcome
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
17
(depressive symptoms) and process variables (mindfulness and rumination). Finally it must be
determined whether the change scores in mindfulness and rumination (pre to post-intervention)
are correlated with depressive symptoms at follow-up. This third step would use multiple
regression, with depressive symptoms at follow-up as the dependent variable, and mindfulness
intervention and changes scores for mindfulness and rumination as predictors. This would enable
a test of whether change in mindfulness and rumination between baseline and post-intervention
accounted for some of the variance in depressive symptoms post-intervention, after the effect of
the intervention was included in the equation. If the impact of the mindfulness intervention on
depressive symptoms at follow-up was fully mediated by change in mindfulness and rumination,
the regression coefficient for the mindfulness intervention as a predictor of depressive symptoms
at follow-up would be zero.
Sensitivity analyses were conducted to ensure the pattern of findings were robust and not
explained by other factors. Sensitivity analyses included analyses that did not include covariates.
The results conclude with exploratory within-groups one-tailed Pearson’s correlations of
the outcome (depressive symptoms), process variables (mindfulness and rumination) and
practice. All data were analysed using SPSS version 19.0.
Results
Five hundred and twenty two young people participated in the study; 256 in the
intervention schools, and 266 in the control schools. Young people attended one of twelve
schools; six of which were private schools, and six of which were publicly funded, with one
selective grammar school in both the intervention and control group. The schools published
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
18
exam results evidenced varied levels of academic attainment across the sample, and a small
cohort of young people in special needs schools was included in each condition.
Ninety-six percent of participants attended six or more sessions of the nine-session
intervention and attrition from the programme was lower than 1%. Seven trained teachers, of
whom 6 were male, delivered the intervention. Teachers had an average of 12 years of general
teaching experience, and an average of 1.8 years experience delivering the mindfulness
intervention. The two course developers had the longest experience of delivering the
intervention, having taught if for 3 years since developing the programme.
Most of the schools (5/6 experimental schools) delivered the programme as a universal
intervention; therefore these young people took part in the programme during the regular school
timetable. However one class (N = 26) participated in the programme voluntarily during lunch
break.
The characteristics of participants in each group at baseline are reported in Table 1. The
intervention arm contained a higher percentage of female participants than the control arm (χ² (1)
= 15.00, p = <.001), and the sample as a whole contained fewer females than males in both the
control and intervention arm (approximately two thirds of the sample were male). There were no
significant differences between the intervention and control group on age, ethnicity, depressive
symptoms and rumination, however baseline levels of mindfulness were significantly higher in
the control group than the intervention group t(424) = 2.26, p = .024.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
19
Table 1
Baseline characteristics of participants in the MiS intervention and control group.
Variable
MiS Intervention
Control
(n=256)
(n=259)
Female, %
36.5
19.2
Age in years at baseline, mean (SD)
14.9 (1.5)
14.7 (1.4)
White, %
75.6
75.1
Asian, %
9.6
9.8
Chinese, %
1.6
3.5
Black, %
4.4
3.5
Mixed, %
4.8
5.2
Other, %
4.0
2.9
Ethnicity
Depressive symptoms (CES-D), M (SD)
15.1 (4.0)
14.95 (3.7)
Mindfulness (CAMS-R), M (SD)
30.5 (5.3)
31.6 (4.8)
Rumination (Rumination CERQ subscale), M (SD)
10.1 (3.6)
10.1 (3.7)
Note. MiS = Mindfulness in schools; CES-D = Center for Epidemiological Studies Depression
Scale; CAMS-R = Cognitive and Affective Mindfulness Scale-Revised; CERQ = Cognitive
Emotion Regulation Questionnaire.
a
Sample sizes range from 228 to 256 in the intervention arm and 169 to 259 in the control arm.
Between-groups comparisons of the effect of the MiS programme on depressive symptoms
The primary hypothesis for this study was that young people who participated in the
mindfulness programme would experience a reduction in depressive symptoms following the
intervention relative to controls, and that this would be maintained at follow-up. This prediction
was supported; intervention participants experienced significantly fewer depressive symptoms
post-intervention compared to control participants, even after controlling for gender, age,
ethnicity, and depressive symptoms at baseline F(1, 375) = 15.78. This reduction was maintained
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
20
at three-month follow-up; intervention participants continued to show lower levels of depressive
symptoms at follow-up relative to control participants, after controlling for gender, age, ethnicity
and baseline depressive symptoms F(1, 378) = 10.22. Table 2 displays unadjusted and adjusted
means including confidence intervals and p values for the intervention and control group at postintervention and follow-up.
Table 2
Mean differences in outcome and process variables between study arms at post-intervention and
three-month follow-up.
Mean (SD) for trial
arms
Outcomes
Intervention
Control
(I)
(C)
Adjusted
Unadjusted
Mean
Mean
95 %
difference
difference
Confidence
(I – C)
(I – C)
Interval
P value
Post-intervention
Depressive symptoms (CES-D) 14.3 (3.5)
15.4 (4.0)
-1.1
-1.45
-2.18 to -0.74
<.001*
Mindfulness (CAMS-R)
31.0 (5.5)
31.2 (5.2)
-0.2
0.48
-0.74 to 1.35
.565
Rumination (CERQ subscale)
11.0 (3.4)
10.4 (3.6)
0.6
.357
-0.38 to 1.09
.339
Depressive symptoms (CES-D) 14.6 (3.7)
15.6 (4.6)
-1
-1.25
-2.03 to -0.48
.002*
Mindfulness (CAMS-R)
31.3 (5.4)
31.5 (5.8)
-0.2
1.02
0.05 to 1.99
.039*
Rumination (CERQ subscale)
10.1 (3.6)
10.9 (3.6)
-0.8
-0.94
-1.64 to -0.24
.008*
3 month follow-up
Note. CES-D = Center for Epidemiological Studies Depression Scale; CAMS-R = Cognitive and
Affective Mindfulness Scale-Revised; CERQ = Cognitive Emotion Regulation Questionnaire.
a
* = p < .05.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
b
21
At post intervention, the sample sizes range from 215 to 234 in the intervention arm and 140 to
147 in the control arm.
c
At 3 month follow-up, the sample sizes for range from 218 to 237 in the intervention arm and
146 to 149 in the control arm.
Between-groups comparisons of the effect of the MiS programme on mindfulness and
rumination
The second hypothesis for this study was that young people would learn to respond more
adaptively, that is their tendency to use mindfulness would be enhanced, and their tendency to
ruminate reduced following the programme, and this effect would be maintained at follow-up.
In between-groups analyses of mindfulness, contrary to predictions, an ANCOVA found
no main effect of experimental group on levels of mindfulness post-intervention, after
accounting for gender, age, ethnicity and baseline levels of mindfulness, F(1, 372) = .33. That is,
levels of mindfulness were not altered immediately following the intervention. However at threemonth follow-up, after adjusting for the same covariates, there was a main effect of experimental
condition on mindfulness, F(1, 380) = 4.72. The adjusted mean difference reported in table 2
suggests participants who received the intervention reported a significantly greater propensity to
be mindful at three-month follow-up compared to control participants.
In between-groups analyses of rumination, also contrary to predictions, an ANCOVA
found no main effect of experimental group on levels of rumination post-intervention after
accounting for gender, age, ethnicity and baseline levels of rumination, F(1, 349) = .916. This
suggests that like mindfulness, rumination was not altered immediately after the intervention.
However at three-month follow-up, after adjusting for the same covariates, there was a
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
22
significant main effect of experimental condition on rumination F(1, 358) = 7.04. The adjusted
mean difference shown in table 2 suggests participants who received the intervention reported a
significantly reduced tendency to ruminate at follow-up compared to controls.
In summary, after controlling for covariates, neither process variable (mindfulness or
rumination) appeared to have been changed immediately following the intervention, however as
predicted, by follow-up intervention participants were more mindful, and ruminated less.
Mindfulness and rumination: Mediators of change in depressive symptoms?
The conditions for mediation were not met in this study, as depressive symptoms
reduced post-intervention, which occurred prior to changes in mindfulness and rumination
(process variables) at follow-up. Therefore it was not possible to carry out the planned withingroups mediation analyses (Kazdin, 2007), as the temporal sequence of events could not be
established.
Sensitivity Analyses
Analyses excluding covariates found the same pattern as the main findings, aside from
mindfulness, where not including covariates led to a non-significant finding at follow-up; that is
levels of mindfulness were not significantly different at follow-up without any covariates (see
Appendix A for details).
Exploratory analyses of outcome, process variables, and practice
Intervention participants reported levels of general mindfulness practice since the end of
the intervention to be 3.93 (SD = 0.95), on a six-point scale (from 1 = never to 6 = almost every
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
23
day). A score of three corresponds to practicing mindfulness two to three times a week, and a
score of four about once a week, suggesting that on average, participants who received the
intervention practiced about once a week. These descriptive statistics suggest that the
mindfulness exercises were used reasonably regularly although not very frequently by
participants after the intervention came to an end.
To better understand the relationships that variables had with one another and particularly
to get a sense of how practice affected depressive symptoms and process variables (mindfulness
and rumination), within-groups one-tailed Pearson’s correlations were carried out (see Table 3).
Cohen (1988, 1992) suggested that r = .10 represents a small correlation, r = .30 represents a
medium correlation, and r = .50 represents a large correlation.
Table 3 shows within-groups correlations between practice and depressive symptoms
post-intervention and at follow-up for depressive symptoms, mindfulness, and rumination. Postintervention, depressive symptoms were negatively correlated with practice. Practice was
positively correlated with mindfulness post-intervention, but not significantly correlated with
rumination post-intervention. At three-month follow-up, practice was negatively correlated with
depressive symptoms, and positively correlated with mindfulness, and counter to what theory
would predict, rumination.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
24
Table 3
Within-groups Pearson’s correlations between practice, depressive symptoms, mindfulness and
rumination for intervention participants at post-intervention and follow-up.
Mindfulness Practice
Post-intervention
Depressive symptoms
Mindfulness
Rumination
r = -.192**
r = .227 ***
r = 0.104
Follow-up
Depressive symptoms
Mindfulness
Rumination
r = -.180**
r = .223 ***
r = 0.181**
Note. ** = p < .01, *** = p < .001
Discussion
This non-randomised controlled feasibility study sought to determine whether a universal
intervention designed to teach mindfulness to young people would reduce the extent to which
they experienced depressive symptoms immediately after the intervention and at follow-up,
during the stressful exam period, compared to young people in matched groups who did not
receive the intervention. Further, it aimed to identify what factors might contribute to such a
reduction, and predicted that the intervention would increase young people’s propensity to be
mindful, and reduce their tendency to ruminate. It was predicted that change in depressive
symptoms post-intervention would be mediated by increased mindfulness and reduced
rumination. Finally, it explored relationships between the extent to which young people practiced
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
25
mindfulness and outcome (depressive symptoms) and process variables (mindfulness and
rumination).
In relationship to the primary outcome for the study, depressive symptoms, the main
hypothesis was supported. As predicted, participants reported experiencing fewer depressive
symptoms following the intervention than participants who did not receive the intervention in all
analyses. Despite the three-month follow-up occurring during a period hypothesised to be highly
stressful (the school exam period), the reduction in depressive symptoms in intervention
participants was maintained. This suggests that even during an academically challenging time,
participants still experienced benefit from the intervention. These findings resonate with a recent
study of MBSR that reduced depressive symptoms in adolescents presenting with mental health
problems (Biegel et al., 2009), however the present study differed in that it measured the impact
of a universal mindfulness intervention. This study therefore contributes to the existing research
that mindfulness can reduce depressive symptoms in a clinical population of young people, with
the finding that mindfulness can reduce depressive symptoms in a non-clinical population of
young people. The findings are in contrast to those of recent large-scale study of a universal CBT
intervention that did not produce change in depressive symptoms in at-risk adolescents, if
anything, intervention participants experienced a slight increase in depressive symptoms, which
the authors attributed to greater awareness of depressive symptoms (Stallard et al., 2012). In this
study, it could also be expected that mindfulness practice led to a greater awareness of depressive
symptoms, yet a reduction in depressive symptoms still occurred, suggesting this intervention
offered benefits over and above heightened awareness of existing symptoms. One possible
explanation for the difference in findings between these studies is that mindfulness may target
the mechanisms that maintain sub-threshold depressive symptoms more effectively than CBT.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
26
Although CBT is an established and effective therapy for the treatment of major depression
(NICE, 2009), remarkably little is known as to how it effects change (Kazdin, 2007). It is not
implausible that CBT and mindfulness work through different mechanisms. Although CBT and
mindfulness programmes for depressive symptoms share the same aim, they endeavour to
achieve it through very different means: CBT emphasises changing the content of thoughts,
whereas mindfulness emphasises changing the relationship with thoughts. It could be the case
that changing the relationship with thoughts may be more effective than changing the content of
thoughts in reducing sub-threshold depressive symptoms. Further research that utilises designs
that enable investigation of mechanisms of change is required to establish what accounts for
effectiveness in both mindfulness and CBT interventions.
The second hypothesis for this study, that the universal mindfulness intervention would
enhance young people’s capacity for mindfulness and reduce their tendency to ruminate, was
supported to some extent. Contrary to what was predicted, no changes were observed in
mindfulness or rumination immediately following the intervention. However by follow-up,
young people who had received the intervention reported significantly lower levels of rumination
than control participants, as predicted. As a result of changes in mindfulness and rumination
occurring at follow-up, after the observed change in depressive symptoms post-intervention, it
was not possible to compute the meditational analyses (Kazdin, 2007). Therefore it was not
possible to test the third hypothesis; that change in depressive symptoms occurred as a result of
increasing young people’s propensity for mindfulness and reducing their tendency to ruminate.
The reported increase in mindfulness, and reduction in rumination is consistent with research on
MBSR with predominantly non-depressed adults (Deyo et al., 2009), suggesting mindfulness
interventions may well benefit young people in the same way as adults; by enhancing
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
27
mindfulness and reducing rumination. The delayed effect on rumination parallels the findings of
a study of MBSR with a non-clinical sample of adults (Robins et al., 2012), which reported
significant reductions in rumination at two-month follow-up but not post-intervention, which the
authors attributed to the effect of practice.
There may be a number of explanations for the lack of change in mindfulness and
rumination at post-intervention, and subsequent change at follow-up. One possibility is that the
intervention achieved a reduction in depressive symptoms via a different mechanism (or
mechanisms) than those that were hypothesised (mindfulness and rumination). That is,
depressive symptoms may have reduced post-intervention due to an unmeasured third variable,
such as social support from teachers. This is a possibility, however it is perhaps unlikely that a
factor such as social support would have maintained a reduction in depressive symptoms threemonths after the intervention, particularly during a stressful time. One possibility is that this gain
was maintained as a result of the intervention impacting on a factor known to affect depressive
symptoms, namely, rumination (Burwell & Shirk, 2007; Nolen-Hoeksema & Morrow, 1991).
The findings bear this out as not only was the reduction in depressive symptoms maintained, but
by follow-up, levels of mindfulness had increased and rumination had reduced in participants
who received the intervention, suggesting that the intervention had exerted some effect on the
proposed mechanisms. However the data in this study are not sufficient to conclude what factors
accounted for the reduction in and maintenance of levels of depressive symptoms. Future
research is needed to address the relationship between the observed differences in levels of
mindfulness and rumination, and depressive symptoms. In order to better understand the
mechanisms of change, future studies should collect data at multiple time points to ensure
change in mediating variables is detected prior to change in depressive symptoms. In addition, it
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
28
is recommended that a range of measures are used in the evaluation of complex interventions
(Craig et al., 2008), in order that a range of possible mediators can be accounted for, such as
social support from teachers. A stronger design would include an active control condition (e.g.
psychoeducation sessions), in order that non-specific effects of receiving an intervention could
be controlled for, to determine the effects of the intervention that are uniquely attributable to
mindfulness.
Exploratory correlational findings suggest avenues for future research; notably, the
significant positive association between the extent to which young people practiced mindfulness,
and their levels of depressive symptoms both after the intervention and at follow-up. Potentially,
this could suggest that the more young people practiced mindfulness, the greater the reduction
they experienced in depressive symptoms, however as it is not possible to imply causality with
correlational data, it is also possible that young people who were experiencing more depressive
symptoms practiced mindfulness less. There was also a significant positive association between
practice and mindfulness at both post-intervention and follow-up. Theoretically it could be
expected that the more young people practiced mindfulness, the greater the improvement in their
ability to be mindful, although due to the correlational nature of the data, causality cannot be
implied. The findings for rumination were less clear; no significant association was found
between practice and rumination immediately after the intervention, and a positive association
was found between mindfulness and rumination at follow-up. This finding is anomalous to what
theory would predict, as increased practice would be expected to reduce rumination. Further
research is needed to clarify the relationship between mindfulness practice and rumination.
Despite the inability from these data to imply causality, it seems likely that practice
enhanced the extent to which young people benefited from the programme in terms of reducing
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
29
depressive symptoms and increasing mindfulness, as changing habitual ways of responding to
depressogenic thoughts and feelings is likely to require considerable effort and repetition of new
ways of responding, thus effects may not be immediate and would likely depend on practice.
Indeed, recent studies of mindfulness programmes suggest practice is important to outcome in
young people (Biegel et al., 2009; Huppert & Johnson, 2010), and adults (Ramel, Goldin,
Carmona, & McQuaid, 2004). Additionally, studies of MBSR with adults have reported that
intervention effects increase over time, in terms of enhanced mindfulness and reduced
rumination, speaking to the importance of continued implementation of mindfulness to outcome
(Shapiro, Oman, Thoresen, Plante, & Flinders, 2008; Robins et al., 2012). Future studies should
measure practice at several time-points to establish whether practice does indeed predict better
outcome, and to determine what level of practice is required to achieve change. Comparison of
participants randomised to groups that promote either regular or infrequent practice, would
enable researchers to draw causal conclusions about the effects of practice on outcome, and
control for third variables that might otherwise explain the association between practice and
better outcome.
Strengths, limitations and future directions
The present feasibility study had a number of strengths. It examined a universal
mindfulness intervention in a real world context delivered by those that would provide the
intervention in practice: teachers who were either the developers of the intervention or had been
trained by them. The sample was large, diverse and matched on key variables, including
individuals from private and state funded schools drawn from an age group at an important
developmental window for developing depressive symptoms (12-16 years). Follow-up occurred
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
30
at a stressful time, the summer exam period, theoretically providing a good test of the
intervention’s effectiveness.
As this was a feasibility study, groups were matched, but not randomised to condition.
Although this was accounted for in analyses by controlling for covariates, the non-randomised
design limits the extent to which the observed effects can be attributed to the intervention and not
individual differences occurring between participants or condition. An example of this is the
greater proportion of females in the sample as a whole and in the intervention group compared to
controls. Randomisation would ensure gender distribution was even between conditions.
A second limitation is the relatively limited range of self-report measures. Future
evaluation studies should measure a wider range of variables, to include variables that may
influence outcome such as history of depressive episodes and anti-depressant use, other potential
outcomes of the intervention such as improved psychosocial functioning, and other potential
mechanisms of change, such as social support. This would enable firmer conclusions to be drawn
as to the effects of the intervention, and the mechanisms through which these effects occur. Selfreport data would be enriched by inclusion of other means of data collection; teacher or parent
observations, diagnostic interviews by assessors blind to condition, and physiological measures
(e.g. in response to mood induction tasks).
Following this feasibility study, evaluation trials are now required that employ
randomised controlled designs with large and diverse samples, and a wide range of
psychometrically robust self-report measures, complimented by additional means of
measurement. Measures taken at multiple time-points will allow the teasing apart of the
mechanisms of change, which is essential to allow future interventions to be tailored to maximise
effectiveness. Longer follow-up periods are needed to assess whether effects are maintained over
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
31
time, and to answer the question of whether reducing depressive symptoms with an intervention
such as this does in fact reduce the risk of developing depression later in life.
Conclusions
This non-randomised controlled feasibility study found as predicted that a universal
mindfulness intervention specifically designed for young people and delivered by trained
teachers in schools resulted in lower levels of depressive symptoms in intervention participants
compared to matched controls after the intervention, an effect that was maintained three months
later during an academically stressful time. It also found evidence that by follow-up the
intervention had increased participants’ tendency to be mindful and reduced their tendency to
ruminate compared to controls, suggesting the intervention impacted on the mechanisms
predicted to reduce depressive symptoms. A randomised controlled study is now required that is
designed to determine the mechanisms that account for change in depressive symptoms; with
longer follow-up periods, a wider range of measured variables and a range of measurement
methods. Further research will allow effective preventative interventions to be implemented that
reduce depressive symptoms in young people and offset the associated distress, disability and
risk of later depression.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
32
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Appendix A: Extended results
Sensitivity Analyses
Analyses without covariates
To investigate whether controlling for covariates in the main analysis accounted for the
pattern of findings, independent groups t-tests were run to test the main hypotheses, that is
whether depressive symptoms, and rumination decreased, and mindfulness increased postintervention and whether these changes were maintained at follow-up in intervention participants
compared to controls.
As was found in the main analyses, an independent groups t-test revealed that
participants who had received the mindfulness intervention experienced significantly fewer
depressive symptoms than control participants t(445) = 3.28, p = .001, a difference that was
maintained at follow-up t(461) = .37, p = .012.
In line with the main findings, independent groups t-tests found no significant
differences in levels of mindfulness post-intervention t(442) = 0.56, p = .58, and unlike the main
findings, no significant difference in mindfulness was found at follow-up t(463) = 2.51, p = .71.
The lack of change in mindfulness at follow-up when not controlling for covariates could well be
a result of the finding that control participants scored higher at baseline on mindfulness, thus
intervention participants may well have increased their level of mindfulness, but compared to a
sample of young people who were already more mindful, this difference may not have been
marked enough to reach significance.
In relation to rumination the results of the main findings were confirmed by
independent groups t-tests which found no significant differences post-intervention in levels of
rumination between intervention and control groups t(429) = -1.68, p = .09, but by follow-up
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
42
found intervention participants did ruminate significantly less than control participants t(455) =
2.24, p = .025.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
43
Appendix B: Instructions for Authors For Behaviour Research and Therapy
Accessed online 2nd April 2013: http://www.elsevier.com/journals/behaviour-research-andtherapy/0005-7967/guide-for-authors
Introduction
Behaviour Research and Therapy encompasses all of what is commonly referred to as cognitive
behaviour therapy (CBT). The focus is on the following: theoretical and experimental analyses of
psychopathological processes with direct implications for prevention and treatment; the
development and evaluation of empirically-supported interventions; predictors, moderators and
mechanisms of behaviour change; and dissemination and implementation of evidence-based
treatments to general clinical practice. In addition to traditional clinical disorders, the scope of
the journal also includes behavioural medicine. The journal will not consider manuscripts
dealing primarily with measurement, psychometric analyses, and personality assessment.
The Editor and Associate Editors will make an initial determination of whether or not
submissions fall within the scope of the journal and/or are of sufficient merit and importance to
warrant full review.
Contact details
Any questions regarding your submission should be addressed to the Editor in
Chief:
Professor G. T. Wilson
Psychological Clinic at Gordon Road
Rutgers
The State
University of New Jersey
41C Gordon Road
Piscataway
New Jersey
088548067
USA
Email: brat@rci.rutgers.edu
Before you Begin
Ethics in Publishing For information on Ethics in publishing and Ethical guidelines for journal publication see
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
44
http://www.elsevier.com/publishingethics and http://www.elsevier.com/ethicalguidelines.
Conflict of Interest All authors are requested to disclose any actual or potential conflict of interest including
any financial, personal or other relationships with other people or organizations within three
years of beginning the submitted work that could inappropriately influence, or be perceived to
influence, their work. See also http://www.elsevier.com/conflictsofinterest.
Submission Declaration Submission of an article implies that the work described has not been published
previously (except in the form of an abstract or as part of a published lecture or academic thesis
or as an electronic preprint, see http://www.elsevier.com/postingpolicy), that it is not under
consideration for publication elsewhere, that its publication is approved by all authors and tacitly
or explicitly by the responsible authorities where the work was carried out, and that, if accepted,
it will not be published elsewhere including electronically in the same form, in English or in any
other language, without the written consent of the copyright-holder.
Changes to Authorship This policy concerns the addition, deletion, or rearrangement of author names in the
authorship of accepted manuscripts:
Before the accepted manuscript is published in an online
issue: Requests to add or remove an author, or to rearrange the author names, must be sent to the
Journal Manager from the corresponding author of the accepted manuscript and must include: (a)
the reason the name should be added or removed, or the author names rearranged and (b) written
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
45
confirmation (e-mail, fax, letter) from all authors that they agree with the addition, removal or
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author being added or removed. Requests that are not sent by the corresponding author will be
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as described above. Note that: (1) Journal Managers will inform the Journal Editors of any such
requests and (2) publication of the accepted manuscript in an online issue is suspended until
authorship has been agreed.
After the accepted manuscript is published in an online issue: Any
requests to add, delete, or rearrange author names in an article published in an online issue will
follow the same policies as noted above and result in a corrigendum.
Copyright Upon acceptance of an article, authors will be asked to complete a 'Journal Publishing
Agreement' (for more information on this and copyright see http://www.elsevier.com/copyright).
Acceptance of the agreement will ensure the widest possible dissemination of information. An email will be sent to the corresponding author confirming receipt of the manuscript together with
a 'Journal Publishing Agreement' form or a link to the online version of this agreement.
Subscribers may reproduce tables of contents or prepare lists of articles including abstracts for
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these cases: please consult http://www.elsevier.com/permissions.
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
46
Retained Author Rights As an author you (or your employer or institution) retain certain rights; for details you are
referred to: http://www.elsevier.com/authorsrights.
Role of the Funding Source You are requested to identify who provided financial support for the conduct of the
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and in the decision to submit the article for publication. If the funding source(s) had no such
involvement then this should be stated. Please see http://www.elsevier.com/funding.
Funding Body Agreements and Policies Elsevier has established agreements and developed policies to allow authors whose
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Open Access This journal offers authors a choice in publishing their research: Open Access; articles
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Access publication fee is payable by authors or their research funder. Subscription; articles are
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access programs (http://www.elsevier.com/access). No Open Access publication fee.
Your publication choice will have no effect on the peer review process or acceptance of your
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honor or reputation.
Creative Commons Attribution-NonCommercial-ShareAlike (CC-BY-NCSA): for non-commercial purposes, lets others distribute and copy the article, to create extracts,
abstracts and other revised versions, adaptations or derivative works of or from an article (such
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work (such as an anthology), as long as they credit the author(s) and provided they do not alter or
modify the article.
To provide Open Access, this journal has a publication fee which needs to be met by the
authors or their research funders for each article published Open Access.
The publication fee
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
48
for this journal is $3000, excluding taxes. Learn more about Elsevier's pricing policy:
http://www.elsevier.com/openaccesspricing.
Language (Usage and Editing Services) Please write your text in good English (American or British usage is accepted, but not a
mixture of these). Authors who feel their English language manuscript may require editing to
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may wish to use the English Language Editing service available from Elsevier's WebShop
http://webshop.elsevier.com/languageediting/ or visit our customer support site
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Submission Submission to this journal proceeds totally online and you will be guided stepwise
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though manuscript source files are converted to PDF files at submission for the review process,
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Submit your article
Please submit your article via http://ees.elsevier.com/brat/
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
49
Preparation
Article structure
Subdivision - Unnumbered sections
Divide your article into clearly defined sections. Each subsection is given a brief heading.
Each heading should appear on its own separate line. Subsections should be used as much as
possible when cross-referencing text: refer to the subsection by heading as opposed to simply
'the text'.
Appendices
If there is more than one appendix, they should be identified as A, B, etc. Formulae and
equations in appendices should be given separate numbering: Eq. (A.1), Eq. (A.2), etc.; in a
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Essential title page information
Title
Concise and informative. Titles are often used in information-retrieval systems. Avoid
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Author names and affiliations
Where the family name may be ambiguous (e.g., a double name), please indicate this
clearly. Present the authors' affiliation addresses (where the actual work was done) below the
names. Indicate all affiliations with a lower-case superscript letter immediately after the author's
name and in front of the appropriate address. Provide the full postal address of each affiliation,
including the country name and, if available, the e-mail address of each author.
Corresponding author
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
50
Clearly indicate who will handle correspondence at all stages of refereeing and
publication, also post-publication. Ensure that phone numbers (with country and area code) are
provided in addition to the e-mail address and the complete postal address. Contact details must
be kept up to date by the corresponding author.
Present/permanent address
If an author has moved since the work described in the article was done, or was visiting at
the time, a 'Present address' (or 'Permanent address') may be indicated as a footnote to that
author's name. The address at which the author actually did the work must be retained as the
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Abstract
A concise and factual abstract is required with a maximum length of 200 words. The
abstract should state briefly the purpose of the research, the principal results and major
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Graphical abstract
A Graphical abstract is optional and should summarize the contents of the article in a
concise, pictorial form designed to capture the attention of a wide readership online. Authors
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51
Preferred file types: TIFF, EPS, PDF or MS Office files. See
http://www.elsevier.com/graphicalabstracts for examples. Authors can make use of Elsevier's
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Highlights
Highlights are mandatory for this journal. They consist of a short collection of bullet
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http://www.elsevier.com/highlights for examples.
Keywords
Immediately after the abstract, provide a maximum of 6 keywords, to be chosen from the
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Abbreviations
Define abbreviations that are not standard in this field in a footnote to be placed on the
first page of the article. Such abbreviations that are unavoidable in the abstract must be defined
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Acknowledgements
Collate acknowledgements in a separate section at the end of the article before the
references and do not, therefore, include them on the title page, as a footnote to the title or
otherwise. List here those individuals who provided help during the research (e.g., providing
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
52
language help, writing assistance or proof reading the article, etc.).
Shorter communications
This option is designed to allow publication of research reports that are not suitable for
publication as regular articles. Shorter Communications are appropriate for articles with a
specialized focus or of particular didactic value. Manuscripts should be between 3000-5000
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Artwork
Electronic artwork
General points
Make sure you use uniform lettering and sizing of your original artwork. Embed the
used fonts if the application provides that option. Aim to use the following fonts in your
illustrations: Arial, Courier, Times New Roman, Symbol, or use fonts that look similar. Number
the illustrations according to their sequence in the text. Use a logical naming convention for your
artwork files. Provide captions to illustrations separately. Size the illustrations close to the
desired dimensions of the printed version. Submit each illustration as a separate file. A detailed
guide on electronic artwork is available on our website:
http://www.elsevier.com/artworkinstructions You are urged to visit this site; some excerpts
from the detailed information are given here.
Formats
If your electronic artwork is created in a Microsoft Office application (Word, PowerPoint,
Excel) then please supply 'as is' in the native document format. Regardless of the application
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53
used other than Microsoft Office, when your electronic artwork is finalized, please 'Save as' or
convert the images to one of the following formats (note the resolution requirements for line
drawings, halftones, and line/halftone combinations given below): EPS (or PDF): Vector
drawings, embed all used fonts. TIFF (or JPEG): Color or grayscale photographs (halftones),
keep to a minimum of 300 dpi. TIFF (or JPEG): Bitmapped (pure black & white pixels) line
drawings, keep to a minimum of 1000 dpi. TIFF (or JPEG): Combinations bitmapped line/halftone (color or grayscale), keep to a minimum of 500 dpi.
Please do not: Supply files that are
optimized for screen use (e.g., GIF, BMP, PICT, WPG); these typically have a low number of
pixels and limited set of colors; Supply files that are too low in resolution; Submit graphics that
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Tables
Number tables consecutively in accordance with their appearance in the text. Place
footnotes to tables below the table body and indicate them with superscript lowercase letters.
Avoid vertical rules. Be sparing in the use of tables and ensure that the data presented in tables
do not duplicate results described elsewhere in the article.
References
Citation in text
Please ensure that every reference cited in the text is also present in the reference list (and
vice versa). Any references cited in the abstract must be given in full. Unpublished results and
personal communications are not recommended in the reference list, but may be mentioned in
the text. If these references are included in the reference list they should follow the standard
reference style of the journal and should include a substitution of the publication date with either
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54
'Unpublished results' or 'Personal communication'. Citation of a reference as 'in press' implies
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Web references
As a minimum, the full URL should be given and the date when the reference was last
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Reference management software
This journal has standard templates available in key reference management packages
EndNote (http://www.endnote.com/support/enstyles.asp) and Reference Manager
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Reference style
Text
Citations in the text should follow the referencing style used by the American
Psychological Association. You are referred to the Publication Manual of the American
Psychological Association, Sixth Edition, ISBN 978-1-4338-0561-5, copies of which may be
ordered from http://books.apa.org/books.cfm?id=4200067 or APA Order Dept., P.O.B. 2710,
Hyattsville, MD 20784, USA or APA, 3 Henrietta Street, London, WC3E 8LU, UK. List. References should be arranged first alphabetically and then further sorted
chronologically if necessary. More than one reference from the same author(s) in the same year
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55
must be identified by the letters 'a', 'b', 'c', etc., placed after the year of publication. Examples
Reference to a journal publication: Van der Geer, J., Hanraads, J. A. J., & Lupton, R. A.
(2010). The art of writing a scientific article. Journal of Scientific Communications, 163, 51–59.
Reference to a book: Strunk, W., Jr., & White, E. B. (2000). The elements of style. (4th ed.).
New York: Longman, (Chapter 4). Reference to a chapter in an edited book: Mettam, G. R.,
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Z. Smith (Eds.), Introduction to the electronic age (pp. 281–304). New York: E-Publishing Inc.
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Elsevier accepts video material and animation sequences to support and enhance your
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56
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Submission checklist
The following list will be useful during the final checking of an article prior to sending it
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Ensure that the following items are present: One author has been designated as the
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57
and in print, or to be reproduced in color on the Web (free of charge) and in black-and-white in
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After Acceptance
Use of the Digital Object Identifier
The Digital Object Identifier (DOI) may be used to cite and link to electronic documents.
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the publisher upon the initial electronic publication. The assigned DOI never changes. Therefore,
it is an ideal medium for citing a document, particularly 'Articles in press' because they have not
yet received their full bibliographic information. Example of a correctly given DOI (in URL
format; here an article in the journal Physics Letters B):
http://dx.doi.org/10.1016/j.physletb.2010.09.059
When you use a DOI to create links to
documents on the web, the DOIs are guaranteed never to change.
Proofs
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If you do not wish to use the PDF annotations function, you may list the corrections (including
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58
replies to the Query Form) and return them to Elsevier in an e-mail. Please list your corrections
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Offprints
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59
Elsevier NIH Policy Statement
As a service to our authors, Elsevier will deposit to PubMed Central (PMC) author
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at:
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Elsevier facilitates author response to the NIH voluntary posting request (referred to as the NIH
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Author Inquiries
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visit http://www.elsevier.com/artworkinstructions. Contact details for questions arising after
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60
acceptance of an article, especially those relating to proofs, will be provided by the publisher.
You can track accepted articles at http://www.elsevier.com/trackarticle. You can also check our
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MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
61
Appendix C: Ethical Approval
Psychology Research Ethics
Committee
Psychology, College of Life
& Environmental Sciences
Washington Singer Laboratories
Perry Road
Exeter
EX4 4QG
Telephone +44 (0)1392 724611
Fax
+44 (0)1392 724623
Email
Marilyn.evans@exeter.ac.uk
To:
From:
CC:
Re:
Date:
Willem Kuyken, Kath Weare, Felica Huppert, Nicola Motton
Cris Burgess
Application 2011/527 Ethics Committee
March 12, 2016
The School of Psychology Ethics Committee has now discussed your application, 2011/527 – An
evaluation of a mindfulness programme in schools. The project has been approved in
principle for the duration of your study and I can now confirm that we are happy for you to
proceed, using the measures you supplied and a parental opt-out procedure. As an advisory note,
you may wish to consider informing participants at the briefing stage of the nature and number of
the items you intend to ask them to complete, however, this is at your discretion.
The agreement of the Committee is subject to your compliance with the British Psychological
Society Code of Conduct and the University of Exeter procedures for data protection
(http://www.ex.ac.uk/admin/academic/datapro/). In any correspondence with the Ethics
Committee about this application, please quote the reference number above.
I wish you every success with your research.
Cris Burgess
Chair of Psychology Research Ethics Committee
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
62
Appendix D: Questionnaire Measures
CES-D 8 Item Version
Here is a list of the ways you might have felt or behaved during the past week. Please indicate
how much of the time during the past week:
None or
Some of
Most of
All or almost
almost
the time
the time
all of the
none of the
time
time
… you felt depressed?
1
2
3
4
1
2
3
4
… your sleep was restless?
1
2
3
4
… you were happy?
1
2
3
4
… you felt lonely?
1
2
3
4
… you enjoyed life?
1
2
3
4
… you felt sad?
1
2
3
4
… you could not get going?
1
2
3
4
… you felt that everything you did was
an effort?
MINDFULNESS FOR ADOLESCENT DEPRESSIVE SYMPTOMS
Cognitive and Affective Mindfulness Scale-Revised CAMS-R
Item rated on a Likert Scale from 1 to 4:
1 = rarely / Not at all; 2 = Sometimes; 3= Often; 4 = Almost Always
People have a variety of ways of relating to their thoughts and feelings. For each of the items
below, please rate how much each of these ways applies to you.
1. It is easy for me to concentrate on what I am doing.
2. I am preoccupied by the future.
3. I can tolerate emotional pain.
4. I can accept things I cannot change.
5. I can usually describe how I feel at the moment in considerable detail.
6. I am easily distracted.
7. I am preoccupied by the past.
8. It's easy for me to keep track of my thoughts and feelings.
9. I try to notice my thoughts without judging them.
10. I am able to accept the thoughts and feelings I have.
11. I am able to focus on the present moment.
12. I am able to pay attention to one thing for a long period of time.
63
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64
CERQ: Rumination Scale
Four items are rated on a five-point scale:
1 = Never or almost never, 2 = Sometimes, 3 = Regularly, 4 = Often, 5 = Always of almost
always.
Sometimes nice things happen in your life and sometimes unpleasant things might happen. When
something unpleasant happens to you, how often do you have each of the following thoughts?
1) I am preoccupied with what I think and feel about what I have experienced
2) I dwell upon the feelings the situation has evoked in me
3) I think about how I feel about what I have experienced
4) I want to understand why I feel the way I do about what I have experienced
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65
Appendix E: Parent and Participant Consent Forms, Participant Debriefing form
Dear Parents
Next term your child will be learning about mindfulness once a week for 9 weeks during [PSHE
lessons]. Mindfulness is a training in concentration and self-awareness which can help young
people with stress and anxiety. Pupils have said that this programme can help them not only with
stress but with concentration, sleep and even sport. For further information on the specific course
we will be teaching please visit the Mindfulness in Schools Project website:
www.mindfulnessinschools.org. For a broader overview of mindfulness in the adult world, a
website has been set up by the Mental Health Foundation: www.bemindful.co.uk.
We are currently working with Professors Katherine Weare and Willem Kuyken at Exeter
University and Professor Felicia Huppert at Cambridge University to see how effective this
programme. This would involve your child completing some short questionnaires before, after,
and three months following the course. During the lessons, the teachers may be filmed for the
sole purpose of monitoring the quality of their teaching.
Your child’s participation in the evaluation is voluntary and they will be asked at school if they
wish take part in the evaluation. They can choose not to take part or withdraw from the study at
any time without giving a reason and we will find an alternative activity for them during the
time. The information provided by your child will be anonymous so that it is impossible to trace
this information back to them individually. Following completion of the study, pupils will be
provided with feedback about the study findings, including some individualised feedback on
their scores if they specifically ask for this.
As a parent you can withdraw your child from the evaluation research if you do not wish them to
take part. If you have any questions, please contact me using the details below.
If you wish for your child to not take part in this research please complete and return the slip
below by [date 2 weeks following]
With best wishes
[Class teacher]
[contact details of class teacher]
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66
Attached Slip:
If you wish for your child not to take part in this research then please complete and return this
form via mail or email by [date] and their involvement will not be requested.
I, ________________________________(NAME) do not wish for my child
________________________________(CHILD’S NAME)
to participate in this study.
Date:
Participant Consent Form
Your school is offering or considering offering a programme that aims to help young people
learn, cope with stress and enjoy life to the full. It is called the .B mindfulness in schools
programme and you can read more about it at www.mindfulnessinschools.org. We want to find
out how useful students find this programme by looking at things like stress, well-being and
learning before and after the programme.
You are in a school where the .B programme is being offered and taking part involves filling out
some questionnaires before the programme starts, immediately after the programme completes
and then again in term after the programme completes. Each set will take no more than 50
minutes of your time.
Or You are in a school where we plan to offer the .B programme, but for now we are a
comparison site for schools that are already teaching the programme. Taking part involves filling
out some questionnaires in January, again at the end of term and then again in the summer term.
Each set will take no more than 50 minutes of your time.
If you have questions or concerns about any of the questions please speak to your teacher. You
don’t have to take part in this. If you want to stop taking part at any time, just let your teacher
know.
All information you give will be kept anonymous and confidential.
If you have any questions, just ask your teacher.
[Additional part to be presented before the online questionnaires:]
If you are happy to take part, please click to get to the next page and start the questionnaires.
[Additional part to be presented after the online questionnaires:]
Do you want some feedback on how you did in the questionnaires? If tick here and we will send
you an email at the end.
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Participant Debriefing Form
Thank you for taking part in this study.
Some of you who filled out these questionnaires also took part in a programme called “.B”,
designed to teach people ways of coping with the stresses and strains of everyday life.
The school were hoping to see whether people that took part in “.B” changed in any way, such as
whether they coped with stress better, or felt any happier overall.
Your taking part in this has helped the school find out whether the “.B” programme is helpful.
Thank you once again for taking part.
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Dissemination Statement
The findings of the current study will be disseminated in two ways; an individualised
school profile (including details of how the school scored compared to the rest of the sample
according to depression and wellbeing) as well as overall study results will be provided to all
schools that took part, and the findings will be submitted for publication in Behaviour Research
and Therapy. Behaviour Research and Therapy is a fitting journal as it invites publications that
evaluate interventions, and seek to answer questions relating to the process as well as the
outcomes of interventions. The journal also invites publications that examine the processes that
underlie psychological disorders, and considers how this knowledge can be applied to
preventative interventions. This speaks to the issues discussed in this paper relating to the
processes that maintain depressive symptoms and lead to depression. The findings will also
contribute to the formulation of the next phase of evaluating this mindfulness intervention, which
will be conducted by the wider research team involved in this project (Kuyken et al., 2013).